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Summary Introduction Phthiriasis palpebrarum is an ectoparasitosis in which Phthirus pubis infest the eyelashes. It is rare and it can easily be misdiagnosed as blepharitis. The purpose of this study is to describe seven cases of phthiriasis palpebrarum so as to discuss its mode of infestation, diagnosis and treatment. Patients and methods This is a study of all cases of phthiriasis palpebrarum reported in our laboratory. For each patient, an ophthalmic examination and parasitological examination of the eyelashes were performed. Results There were five men and two women. Their ages ranged from 4 to 50 years with an average of 21.57 years. There were four children and three adults. The main symptom was itching of the eyelids. Clinical signs included reddish-brown crusts at the base of the eyelashes in all the cases and visible lice and nits in three cases. Biomicroscopic examination showed lice and nits anchored to the eyelashes in three cases. In the other two cases, the initial diagnosis was felt to be blepharitis. In all cases, the diagnosis of phthiriasis palpebrarum was confirmed by parasitological examination of eyelashes, which revealed the presence of adult and nit forms of Phthirus pubis . The number of adult lice ranged from 1 to 30. In all cases, treatment was based on mechanical removal of both the lice and nits. Outcomes were favorable without recurrence. Conclusion In conclusion, phthiriasis palpebrarum can be easily diagnosed by close examination of the eyelashes and eyelid margins at the slit lamp and can be managed mechanically. Parasitological examination of the eyelashes can confirm the diagnosis.

Tacrolimus 0.03% ointment is licensed for second-line treatment of children with atopic dermatitis (AD). Although data are available from clinical trials, no study has enrolled only second-line patients. This double-blind, non-inferiority study compared tacrolimus 0.03% and fluticasone 0.005% ointments in children with moderate-to-severe AD, who had responded insufficiently to conventional therapies. Children (aged 2-15 yr) were randomized to tacrolimus ointment (n = 240) or fluticasone ointment (n = 239), twice daily until clearance or for a maximum of 3 wk and, if lesions remained, once daily for up to 3 wk further. Primary end-point was week 3 response rate (improvement of >or=60% in modified Eczema Area and Severity Index and not withdrawn for lack of efficacy). Secondary end-points included pruritus and sleep quality, global assessment of clinical response, incidence of new flares and safety. Response rates were 86.3% with tacrolimus ointment and 91.5% with fluticasone. Lower limit of the 95% confidence interval was -11.8%, exceeding the non-inferiority limit of -15% and meeting the primary end-point. Moderate or better improvement on the physicians' global assessment occurred in 93.6% and 92.4% of patients in the tacrolimus ointment and fluticasone arms, respectively, while median pruritus scores improved by 84.0% and 91.5%. Sleep quality improved by approximately 92% in both treatment arms. After day 21, new flare-up occurred in 5.5% and 11.3% of patients receiving tacrolimus ointment and fluticasone, respectively; mean times to new flares were 6.5 +/- 5.0 and 8.6 +/- 5.2 days. Adverse events were similar between the two arms, with the exception of application-site skin burning sensation in the tacrolimus ointment group. In conclusion, efficacy of tacrolimus 0.03% ointment as second-line treatment was not inferior to that of fluticasone 0.005% ointment, with similar benefits on global disease improvement and quality of sleep.

Background: Risk factors for erysipelas (cellulitis) were rarely evaluated in controlled studies. Regional variations of these risk factors have never be assessed. Objective: To assess risk factors for erysipelas of the leg in Tunisia. Subjects and Methods: Case-control study in seven hospital centers in Tunisia. Cases were 114 consecutive patients with erysipelas of the leg [sudden onset (Results: In multivariate analysis, disruption of the cutaneous barrier (i.e. traumatic wound, toe-web intertrigo, excoriated leg dermatosis or plantar squamous lesions) and leg edema were independently associated with erysipelas of the leg, with respective odds ratios of 13.6 (95% confidence interval: 6.0–31) and 7.0 (1.3–38). No association was observed with diabetes, alcoholism, or smoking. Conclusions: We confirmed the major role of local risk factors and the minor role of general risk factors for erysipelas of the leg, in a setting different than the one previously studied. Detecting and treating toe-web intertrigo and traumatic wounds should be considered in the prevention of erysipelas of the leg.

Recent studies have suggested that in Tunisia, pemphigus foliaceus is more frequent in young women than expected. To confirm these findings, we compared the incidence rates of pemphigus in Tunisia as a whole and in a large area of France, New cases of pemphigus were detected retrospectively from dermatology departments and pathology laboratories over a 6-year period and classified as pemphigus vulgaris or foliaceus according to the pathology. In France, the incidence rate was 1.7 cases per million per year (95% confidence interval 1.4 to 2.1). Pemphigus vulgaris accounted for 73% of all cases, incidence increased with age, and the female-to-male sex ratio was 1.2. The incidence rate was significantly higher in Tunisia than in France: 6.7 cases per million per year (95% confidence interval 5.8 to 7.7); pemphigus foliaceus was more frequent (61%), the female-to-male sex ratio was 4.1, and the incidence rate was higher in young women. The incidence rate was 15.5 cases per million per year for pemphigus foliaceus among women aged 25 to 34 years and was even higher in some rural areas, No case was observed among household members or in neonates, and only one case occurred in childhood, Thus, we confirmed that the epidemiology of pemphigus in Tunisia is unusual. High rates of pemphigus foliaceus among young people living in rural areas are reminiscent of Brazilian pemphigus. However, the absence of cases among genetically related household members and during childhood, and the large predominance of women, contrast with Brazilian pemphigus.

Pyoderma gangrenosum (PG) is an uncommon extensive cutaneous ulceration belonging to the neutrophilic disease spectrum. It is associated to a systemic disease in almost 50% of cases. The diagnosis primarily relies on clinico-pathological features and the treatment is empirical. We report a retrospective series of 6 observations of PG (4 women and 2 men, median age = 43 years) enrolled over 15 years. The diagnosis was established based on the presence of 2 major criteria and 2 minor criteria of the disease. In 3 patients, PG was associated to an already known ulcerative colitis. The treatment consisted in general corticotherapy.

Transversal case-control study was conducted among 42 patients aged between 20 and 35 years who had diffuse alopecia. Alimentary inquiry according to the 3-day method was achieved in each case. The following nutriments were evaluated: total proteins, calcium, copper, iron, iodine, magnesium, manganese, phosphorus, potassium, selenium, zinc, omega 3 and omega 6. A control group (composed of 230 individuals), matched for age, gender and metabolic profile was established. These persons did not suffer from hair and nail disorder. The nutriments were codified according to the data of the software Food processor 8.3 version. The data were analyzed using "SPSS" 11.5 version. Comparisons of the means were performed using the Student's t test. ROC graphics allowed to determine the statistically significative limits for the comparison of both groups. On multivariate analysis, only a protein intake was directly associated to alopecia, odds ratio of 1,5 (1,06 - 2,3) p=0,02.

Erythroderma is a severe syndrome and prognostic studies are rare in the literature.Through a retrospective study of erythroderma in adults, we have analysed epidemiological and clinical data and precised the relevant aetiologies and survival in our patients.This study was performed at the Department of Dermatology of Charles Nicolle Hospital of Tunis (1995-2007) including 82 cases of acquired erythroderma (16 years). We have recorded epidemio-clinical, biological and histological data, treatment and outcome. Clinical-histological correlation was analysed [kappa coefficient (kappa)]. Follow-up time and disease-free survival time were calculated as were Kaplan-Meier estimates of overall survival and relapse-free survival for some aetiologies.Erythroderma represented 0.44 per thousand of all dermatoses with an age of 55.13 +/- 18.16 and no sex predilection. Psoriasis was the predominant aetiology (32.9%) with a median duration of 6.75 years and previous one or more episodes of erythroderma. Psoriasis was significantly associated with pruritus (P = 0.0001), pachyonychia (P = 0.00001), palmoplantar keratoderma (P = 0.0001) and hypereosinophilia (P = 0.008). The latter is then not specific for drug induced erythroderma (P = 0.004). Carbamazepine (27.8%) and penicillin (22.2%) were the most implicated drugs. Positive Clinical-histological correlation was found in 77% of cases (kappa = 0.753). Relapse was seen in all aetiologies, but drug reactions and had occurred in the first 3 years in 90% of them. Mortality rate was 11.3 per 1000 patients-years.Our study illustrates the severity of erythroderma. It alters heavily the quality of life of patients which is initially altered by the pre-existent dermatosis. It may be life threatening as mortality rate is high.

Three clinical forms of cutaneous leishmaniasis can be found in Tunisia, i.e. the sporadic form due to Leishmania infantum in the North, the zoonotic epidemic form due to Leishmania major in the center and Southwest, and the chronic cutaneous form due to Leishmania tropica in the South. Unlike cutaneous forms, mucosal involvement is uncommon. The purpose of this report is to describe another case of mucosal leishmaniasis due to contiguity with a skin lesion in a 54-years-old woman. The patient responded well to treatment with meglumine antimoniate.

Endometriosis is defined as the presence of extra-uterine endometrial tissue. The prevalence rate of umbilical endometriosis ranges from 0.5 to 1.0% of all patients with extragenital endometriosis. In this report, we present a case of primary umbilical endometriosis to highlight the challenges encountered during diagnosis. A nulliparous 39-year-old woman presented to our department with a 2-year history of a tender, painful and non-reducible, firm umbilical mass that enlarged slowly reaching 2 cm in diameter. She had never been pregnant nor had any abdominal surgery. There was no sequential bleeding. Ultrasound of the umbilical region showed a well defined, oval shaped anechoic area. Histological examination on a cutaneous biopsy concluded umbilical endometriosis. The patient was subsequently referred to a gynecologist and underwent surgery with en bloc excision of the lesion. Generally, umbilical endometriosis presents as a roundish tumuor that can either partly or completely occupy the umbilical scar with intermittent bleeding. Characteristically, the mass increases with the menstrual cycle, becoming more evident and usually harder and is associated with cyclic pain. Its pathogenesis remains uncertain. Clinical diagnosis is difficult, and umbilical endometriosis can be easily confused with other conditions such as benign and malignant tumours. Ultrasound examination is useful, and surgical excision is the treatment of choice. Several cases of malignant transformation have also been described.

Blepharochalasis is characterized by recurrent painless oedema of the eyelids leading to alteration of periorbital skin with a nearly complete loss of elastic fibers. It usually affects the upper eyelids bilaterally. An 11-year-old girl suffered from recurrent erythematous swelling episodes during 3 months. The manifestations were confined to the periorbital region. She gradually noticed a bilateral loss of elasticity of the skin of the upper eyelid. The skin showed some folding and laxity. A mild aponeurotic ptosis was present. A skin biopsy showed the absence of elastic fibres. Blepharochalasis is a disease of young people. It has been divided in two hypertrophic and atrophic types. The condition typically follows recurrent painless episodes of oedema infiltrating both upper eyelids. The eyelid oedema usually resolves after several days and recures several times a year.

Granuloma annulare (GA) is a palisading granulomatous skin disease. It is a relatively common dermatosis typically characterized by an annular arrangement of erythematous or flesh-coloured papules. The aim of this study was to assess the epidemiological and clinical pattern of GA and its management.A retrospective study dealing with 35 cases of GA collected during an 11-year period from 1995 to 2005 was carried out at the Dermatology Department of Charles Nicolle's Hospital of Tunis.There were 24 females and 11 males including 13 children. Four clinical patterns were observed: localized GA with annular shaped lesions in 22 cases (62.8%), subcutaneous GA in 9 cases (25.7%) with 4 children, combination of localized and subcutaneous patterns in one child (2.8%), generalized GA in one adult-patient (2.8%) and combination of generalized and subcutaneous patterns in 2 cases (5.7%). Associated diabetes mellitus was seen in 9 adults (25%) and thyroid diseases in 2 other adults (5.7%). Topical steroids were proposed in 9 cases with partial resolution in 6 of them. Four patients were treated by hydroxychloroquine with an improvement in 3 of them. Two patients (generalized GA with subcutaneous form and subcutaneous GA) were treated by dapsone with partial clearing.In these series, GA has the same epidemiological and clinical pattern as other series of the literature. Subcutaneous form had a pseudo-rheumatoid presentation in adults and an exclusive involvement of children when it is localized on the scalp. Associated systemic diseases, especially diabetes mellitus, are frequent in the series here observed.

Sarcoidosis is a multisystem disease of unknown etiology characterized by granulomatous infiltration. As clinical features vary among patients from different ethnic groups and geographic areas, local reports are of great interest. The aim of this study was to make an inventory of the clinical presentation of cutaneous sarcoidosis in Tunisia.The study was conducted in an academic teaching hospital, inpatient and outpatient department. The authors retrospectively reviewed the medical records of all patients diagnosed with sarcoidosis at the Dermatological Departement of Charles Nicolle teaching Hospital, Tunis, within a 32-year period.One hundred and eighteen patients were diagnosed to have sarcoidosis, corresponding to 25 males and 93 females. Mean age at presentation was 39.5 years. Childhood sarcoidosis represented 14.4% of cases. Cutaneous involvement was dominated by micronodular lesions. Chest X-rays abnormalities were present in 28 patient/93 (30.1%). Most of them were at stage 1 or 2. Peripheral lymph node enlargement was reported in 15 patients (12.7%). Other internal organ involvements corresponded to: eyes (15 cases); bones (12 cases), joints (5 cases), gasto-intestinal tract (5 cases), upper airways (5 cases), liver (4 cases), kidney ( 1 case) and muscles (1 case). Systemic involvement was noticed in 88% patients with lupus pernio. Treatment modalities included topical and oral corticosteroids, hydroxychloroquine, allopurinol and surgical excision with variables outcomes.The data of this study suggest that sarcoidosis manifests with a wide range of cutaneous lesions in Tunisian patients and that extracutaneous involvement is not rare. Remarkable clinico-epidemiological characteristics are the clear predominance in women, the high frequency of childhood cases and the predominance of micronodular skin lesions.

Cutaneous tuberculosis accounts for 2% of all extrapulmonary tuberculosis and is one of the multiple clinical presentations of extrapulmonary tuberculosis. We report a case of cutaneous tuberculosis with unusual clinical and histological presentations.We report the case of a 29-year-old woman with plurifocal tuberculous lupus. Histological examination of cutaneous lesions revealed the presence of a granuloma with caseum necrosis. Chest X-ray showed a severe pulmonary tuberculosis lesion. The Mantoux test performed by intradermal injection was positive. Skin lesion PCR and sputum culture were negative. Both skin and pulmonary lesions responded to antituberculous treatment.Lupus vulgaris is commonly presents on the head and neck. The diagnosis may be difficult when lupus vulgaris occurs at unexpected sites or in unusual clinical presentations. Caseum necrosis observed in our patient was unusual.

Familial exudative vitreoretinopathy (FEVR) is a well-defined inherited disorder of retinal vessel development. Association of FEVR with other congenital ocular diseases has already been described. We report the first clinical case of FEVR associated with hyaloid artery persistence. An 18-year-old Tunisian woman and four members of her family (mother, two brothers, and sister) presented signs of FEVR. Examination of this patient also revealed functional hyaloid artery persistence in her right eye. These two disorders have many common aspects in their pathological process, in particular vascular endothelial growth factor expression, which can explain this association.

We report three cases of optic disc drusen in children. The children were 5 months, 10 years, and 11 years old. Two of them were male. The optic disc drusen was unilateral in two cases and bilateral in one case. One child had a history of Down syndrome and another one a history of Alagille syndrome. The third child had no particular general history but he had unilateral high myopia with optic disc drusen in the same eye. Fundus examination showed pseudopapilledema in all three cases; the disc appeared elevated and its margins were blurred. Ultrasonography of the eye demonstrated optic disc drusen in the three cases. Optic disc calcification on CT scan was identified in only one case. In children, optic disc drusen are often buried, leading to pseudopapilledema appearance of the optic disc. Ultrasonography is highly sensitive in detecting optic disc drusen, making more expensive investigations unnecessary.

Four cases of tinea faciei that were observed at the Department of Dermatology of Charles Nicolle Hospital in Tunis are reported. All patients were females, ages 54 (patient 1), 38 (patient 2), 30 (patient 3), and 50 (patient 4). The lesions lasted 1 year, 2 months, 4 months, and 1 month, respectively. Tinea faciei was initially suspected in three patients, whereas for the second patient eczema was initially suspected. She was first treated topically with corticosteroids leading to exacerbation. Through mycological examination, Trichophyton rubrum was isolated in three patients, but was negative in patient 2. Three patients recovered completely after one month of griseofulvin associated with topical terbinafine. Patient 3 was topically treated because she was pregnant. Erythematous lesions of the face must be checked for fungi.

Epidemiological studies of skin diseases are rather rare. Most of them are based on hospital attendance. The aim of this study was to determine the spectrum of skin diseases in the Tunis region.This prospective study encompasses consecutive patients attending a number of public or private dermatological outpatient clinics in Tunis from June 1999 to July 2000. Diagnosis was mainly based on clinical findings, but supplemented by further investigations when needed.The total number of patients was 28,244, with 28,515 pathological conditions reported. The mean age was 31.6 years with a M/F sex ratio of 0.82:1. Infections constituted the major group of disorders (38.6%), followed by hair follicle and sebaceous gland diseases (14.3%), allergic skin diseases (13.6%), and tumors (7.8%). Infectious diseases included fungal (16.38), viral (9.9%), and bacterial (9.24%) conditions. Dermatitis accounted for 9.9% of cases and acne for 6.9%. Tumors were mainly benign (7%) and very rarely malignant (0.5%).The survey revealed that more than 50% of the diseases were of infectious origin, followed by hair follicle and sebaceous gland disorders. Socioeconomic status and environmental factors may be responsible for this.

Kindler syndrome is a rare type of genetic skin condition belonging to the class of bullous poikilodermia. We report three new cases of this rare syndrome.This condition was seen in two brothers aged 4 and 14 years and in their sister aged 6 years, born of a first-degree consanguineous marriage in a family with Kindler syndrome of varying degrees of severity. The three patients presented spontaneously regressive bullous eruptions, poikilodermia of gradual onset, major cutaneous atrophy on the back of the hands and the feet, pseudo-syndactyly and photosensitivity. The older brother presented a severe form complicated by chronic terminal renal failure with hydronephrosis secondary to urethral stenosis and hypertension as well as oesophageal stenosis requiring dilatation sessions. Electron microscopy examination of poikilodermic skin showed normal anchoring filaments and proliferation of the basal layer. Electron microscopy examination of rubbed poikilodermic skin from the other two siblings showed cleavage at both the superficial and deep intra-epidermal levels.Diagnosis of Kindler syndrome is based upon clinical evidence. Electron microscopic examination is used in particular to rule out congenital bullous epidermolysis. Detachment of layers at two or three different levels in relation to the dermal-epidermal junction described in the literature forms a specific but inconsistent feature of Kindler syndrome.

To discuss, through a retrospective study, the epidemiological and clinical aspects and the causative agents of fixed drug eruption.Thirteen cases were collected retrospectively during 11 years. There were 10 females and 3 males with a mean age of 44 years.The lesions correspond to erythematous plaques which fade to leave slate-brawn macules in all cases. The most frequent localizations were limbs (12 cases), trunk (6 cases), face (3 cases) ans external genitals (3 cases). Sulfonamides were the most frequent responsible drugs in our series (7 cases).Fixed drug eruption is characterized by one or more erythematous plaques which recur in the same places after challenge. Sulfonamides are actually the most frequent causative drugs in the different series.

The short-term impact of eye muscle surgery on the blood-aqueous barrier has been described by iris fluoresceinangiography and laser tyndallometry. The aim of this study was to investigate the long-term effects of eye muscle surgery on the oxygen supply of the anterior segment of the eye by determination of the corneal endothelial cell density.We investigated the corneal endothelial cell density of 32 patients with unilateral rectus muscle surgery pre- and postoperatively (24 cases of primary surgery on 2 horizontal muscles, 4 revision surgeries on 2 horizontal muscles, and 4 primary eye muscle surgeries on the 2 vertical recti including: 3 transpositions of the lateral halves of the vertical recti additional to recession of the medial rectus and one complete transposition of the two vertical recti). Exclusion criteria were previous intraocular surgery and retinal detachment surgery. Mean age at surgery was 37.5 +/- 16.3 (14.5 to 79.9) years. Mean follow-up time was 5.0 +/- 2.2 (1.9 to 10.1) months. The corneal endothelial cell density (CECD) was quantified by means of a specular microscope (EM-1000, Tomey).The intraocular difference in CECD was not statistically significant either pre- or postoperatively. Mean values were 84 +/- 297 (731 to 700) vs. 52 +/- 357 (600 to 800), p = 0.64. In the subgroups of patients with revision surgery and those with primary eye muscle surgery involving the vertical recti, there was also no significant intraocular difference of CECD.Based on the corneal endothelial cell density, there was no evidence of a chronically decreased oxygen supply of the anterior segment even after complex eye muscle surgery.

Sweet's syndrome is an acute febrile neutrophilic dermatoses. Cutaneous signs are the main manifestations. The objective of this study is to deal with the epidemiological and clinical aspects of the disease and its treatment. It is a retrospective study over a period of 5 years (2000- 2004). We have included all the patients with characteristic clinical, biological and histological features. Five patients had been identified. They were all females. Their mean age was 42, 2 years. All patients had typical clinical, histological and biological features. Crohn disease was associated in one case. Sweet's syndrome responds rapidly to systemic therapy with corticosteroids and/or nonsteridal anti-inflammatory agents. Sweet's syndrome is a rare disease which occurs mainly in middle-aged women. This was found in our study. Corticosteroids are the standard therapy. Several diseases, particularly neoplasms and inflammatory diseases, can bee associated with Sweet's syndrome and condition the prognosis.

Cervico-oculo-acoustic syndrome is an uncommon syndrome consisting of Klippel Feil syndrome, deafness, and Duane syndrome. We relate a new case of cervico-oculo-acoustic syndrome.We report the case of 15-month-old girl referred for esotropia of the right eye. Ocular examination revealed type 1 Stilling Duane syndrome in the right eye, in which we also noted microcornea, iris coloboma, and papillary and inferior chorioretinal coloboma sparing the macular area. The left eye was normal. The physical examination revealed Klippel Feil syndrome characterized by an extremely short neck with limited movement, a low posterior head line and fusion of the cervical vertebrae on radiography. The association of hearing loss (due to agenesis of the external ear) with Klippel Feil syndrome and Stilling Duane syndrome confirmed the diagnosis of cervico-oculo-acoustic syndrome.This case is unique because of the association of cervico-oculo-acoustic syndrome with ocular coloboma of the right eye. This association has not been reported previously in the literature.

With progressive aging of populations, geriatric health care has become a major international issue for health authorities. However, little data is available about geriatric skin diseases. The aim of this study is to determine the pattern of skin disorders among elderly patients seen in private and public skin outpatient clinics in Tunis.We performed a prospective, multicentre and descriptive study of all new skin diseases diagnosed in dermatological outpatients aged over 65 years. This study lasted one year (June 1999 to July 2000) and evaluated the activity of eleven Tunisian dermatologists in private or public practice, who collated all cases of skin diseases diagnosed in their practices.A total of 1518 patients with 1550 new diagnoses were examined. Mean age was 72.6 years with a sex M/F -ratio of 1.41. Fungal infections were the most common conditions (16.9%), followed by tumors 12.8% (benign 63.3%), eczema (11.9%), keratinization anomalies (8.7%), bacterial infections (8.7%), viral infections (6.8%) and pruritus (6.4%). Fungal infections were mainly represented by toe-web intertrigo and onychomycosis. Basal cell carcinoma and epidermoid cysts were the most common malignant and benign tumors respectively.This study reflects the frequency of mycoses, benign tumors and eczema in elderly patients. This is consistent with the results of other studies of the literature showing eczema as the predominant skin disease. The high prevalence of mycosis in our study may be explained by climatic conditions (heat, moisture). Pruritus seems to be frequent in geriatric patients. Skin disorders are an important source of morbidity in elderly patients.

Dermatophytic disease is a rare chronic infection caused by common dermatophytes and characterized by cutaneous and subcutaneous invasion. It is observed mainly in North Africa where it is presumably inherited via an autosomal recessive trait. Cellular immunodeficiency could account for the chronic nature of the disease and for its refractoriness to drug treatment. The purpose of this report is to describe the occurrence of dermatophytic disease in three sisters of consanguineous parents in a rural region of northern Tunisia. To our knowledge, this is the first familial case reported in Tunisia. The most salient features in these patients were early age of disease onset in three females, isolation of Microsporum canis at the beginning of the disease, relatively favorable course with long remissions in two cases, and absence of visceral involvement. Various drugs including antifungal agents and immunostimulants were used for treatment with disappointing results. Surgical excision associated with antifungal agents appeared to be effective in our patients. Dermatophytic disease remains a severe disease due to the possibility of potentially life-threatening visceral involvement.

Mycetomas are inflammatory pseudotumors of chronic and progressive evolution, of fungal (Eumycetoma), or bacterial (Actinomycetoma) origin. We conducted a retrospective study of patients who have been consulted for mycetoma over a period of 28 years. Thirteen cases of mycetomas were collected during the 28-year period, 10 patients were of rural origin. The lesions were localized on the foot in all instances. There was no male predominance. Histopathological examination confirmed mycetoma in all 13 cases and the determination of the infectious agent in 9 cases: 4 actinomycotic and 5 fungal. Microbiological examination identified the species in 7 cases. Bone involvement was found in 10 cases. Eumycetomas were treated by ketoconazole. The other cases were treated as actinomycetomas by antibiotics. The antibiotic treatment was associated with surgical excision in 4 cases and with amputation in 1 case. Mycetomas are rare in Tunisia, and only observed sporadically, for this reason the diagnosis is usually late, with severe functional, psychological, and socioeconomic consequences.

Acrodermatitis enteropathica is a rare autosomal recessive disorder, caused by impaired absorption of zinc from the gastrointestinal tract. Symptoms of acrodermatitis enteropathica occur within the first few months after birth and tend to appear shortly after discontinuation of breast-feeding. We report a breast-fed infant with acrodermatitis enteropathica.A full term, 4-month-old girl, consulted in dermatologic department for persistent and refractory anogenital lesions since the age of 1 month, with progressive erythematous, vesiculous and squamous lesions, sometimes erosive in a peri orificial and acral pattern. She was calm and healthy baby. She was breast feeding. The diagnosis of acrodermatitis enteropathica was confirmed by decreased plasma zinc level (14 microg/100 ml). Breast milk zinc levels was low (46 microg/100 ml), as plasma zinc level of the mother (94 microg/100 ml). A genetic study showed that she was homozygous for the mutation, whereas her brother and parents were heterozygous. She was given zinc sulphate, and her condition has improved significantly.Acrodermatitis enteropathica is characterized by a characteristic clinical feature and the diagnosis is confirmed by decreased plasma zinc level. Acrodermatitis enteropathica in exclusively breast fed infant is rare, it was essentially reported in premature babies. Our case report is particular because it's concerning a full-term breast-fed infant, with zinc deficiency in breast milk and mother's decreased plasma zinc level.

Chronic septic granulomatosis is a disease characterized by an impaired bactericidal potential of the neutrophilic polynuclear. The cutaneous manifestations rarely reveal the disease, but are of considerable interest in the diagnosis, notably during the late onset forms. We report such a case.A 15 year-old girl, born of consanguine parents, had a history of visceral leishmaniasis and hepatic hydatidosis. For the past 3 years she had developed dermatitis lesion on the face and skin folds, chronic folliculitis and suppurating axillary and inguinal lymphoadenitis. The absence of a reduction in tetrazolium nitro blue led to the diagnosis of chronic septic granulomatosis. Prophylactic treatment stabilized the cutaneous lesions.Chronic septic granulomatosis regroups various severe and recurrent manifestations. Its transmission is usually X-linked recessive or, on rare occasions, autosomal recessive. The clinical manifestations leading to the diagnosis are often of very early onset. They are principally pneumonia due to apergillus fumigatus and lymphoadenitis. Cutaneous involvement, although less common, must not be neglected because it can lead to the diagnosis of late onset forms, as in our patient.

Three epidemic-clinical forms of leishmaniasis are found in Tunisia: the sporadic cutaneous form due to L. Infantumin in the North, the zoonotic cutaneous form due to L. Major in the Center and South-West, and the chronic cutaneous form due to L. Tropica in the South. We report 5 cases of mucosal leishmaniasis diagnosed in a Dermatology unit in Tunis.Four women and one man, from the North-west of Tunisia, with a mean age of 42.4 years (range: 8-75 years) presented with leishmaniasis. The lesions were localized on the mucosa of the lips in 4 patients and on the endonasal mucosa with infiltration and nasal obstruction in a 75 year-old female patient. Diagnosis of leishmaniasis was established on direct examination in 4 cases and histological examination in 3 cases and by culture in NNN milieu for one patient exhibiting a MON5 L. Major leishmaniasis. All the patients responded well to treatment with intramuscular meglumine antimoniate (Glucantime). In our 5 patients, the mucosal involvement was not as mutilating, nor resistant to treatment, as that described for the cutaneous-mucosal forms in the New World.Mucocutaneous leishmaniasis, endemic in Central and South America, are due to L. Braziliensis. They provoke mutilating and disfiguring lesions, resistant to treatment. In Tunisia, the forms of the disease observed are dermotropic, usually responsible for cutaneous leishmaniasis. However, mucosal involvement is not uncommon and is characterized by the absence of mutilating lesions and the excellent response to treatment.

Mycosis fungoides is an epidermotropic cutaneous T lymphoma. It's a non Hodgkinian lymphoma. We report the results of a retrospective review of 11 mycosis fungoide seen during 22 years. The frequency of MF was about 39.3% among all cutaneous lymphoma. Six patients were male and 5 were female; the mean age was about 56 years. Mean delay between diagnostic and the first manifestation was about 25 months. All patients had the progressive form: 4 had infiltrate plaques and 7 were at the tumoral phase. Lymph nodes and medullar metastases were noted respectively in 1 and 2 cases. Treatment was mono or polychemotherapy associated in 6 cases with topical drug. Three patients died of their diseases According to our experience and after reviewed the literature, we notice that our patients are slightly younger without male predominance. The diagnostic was done tardily and this may explain the pejorative prognostic.

Topical retinoic acid has demonstrated its efficacy in acne. Glycolic acid has also keratolytic action and could be interesting to treat acne.To evaluate the efficacy and safety of topical glycolic acid (Glyco A 12%) and retinoin acid (Kefrane 0.05%) on facial acne lesions.It was a randomised double blind study of 40 patients, divided in 2 groups, 20 receiving GlycoA cream (Group A) and 20 receiving Kefrane cream (group B). Medical exam was realised by the same physician at day 0, 21 and 45. The improvement of acne as well as side effects were assessed by both the physician and the patients themselves.2 patients developed severe eczema of the face and were excluded (one from group A and one from group B). 22 patients followed totally the study. 90% of group A and 83.3% of group B patients improved significantly their lesions. A comparative tolerability was observed for both groups.Glyco A cream could be a good treatment for acne even in dark skin patients.

The sickness of Kaposi's sarcoma (KS) knows, currently, a renewal of interest since the emergence of 2 new forms: the iatrogenic KS and the epidemic KS. Through a retrospective study on 21 years (1978 to 1998) we have tried to specify the epidemiologic and clinical characters of KS in Tunisia. Our study interests 91 patients: 85 cases of classic KS (94%), 4 cases of iatrogenic KS and 2 cases of epidemic KS. The incidence of iatrogenic KS in renal transplant recipients in our study is 1.9%. A male predominance is found in the 3 forms. The mean age of beginning was 60 years in classic KS and more lower in the 2 other forms (31 years in iatrogenic KS and 46 years in epidemic KS). A predominance of lesions in the lower limbs was found in the 3 forms. The visceral locations was more frequent in iatrogenic KS (3 cases) while it has been found in only 1 case of classic KS. In Tunisia, the classic KS is the most frequent form. In iatrogenic and epidemic KS, visceral lésions are frequent and must be researched systematically.

Desmoglein 1 is the target antigen and probably the initiating immunogen of the autoantibody response in pemphigus foliaceus (PF), a blistering autoimmune skin disease. We previously showed that the desmoglein 1 gene (DSG1) is polymorphic and that one of its variants is associated with the sporadic form of PF observed in France. Herewith, we report, based on a case–control analysis, that the same DSG1 polymorphism participates in susceptibility to the endemic form of PF seen in Tunisia and, thus, show that common genetic factors govern the breakage of tolerance to desmoglein 1 in different epidemiological and environmental situations.

The prevalence of atopic dermatitis is usually high in western countries, varying from 18 p. 100 to 20 p. 100. Recent studies suggest an increasing of this frequency. The aim of our study is to determine the epidemiological and clinical characteristics of atopic dermatitis in Tunisia through the analysis of a retrospective cohort.We retrospectively studied all the medical reports of atopic dermatitis registrated in the department of dermatology during a 7 years period (1992-1998). We analysed epidemiological and clinical features of every medical report. We used diagnosis criteria of Hanifin and Rajka.Four hundred fifty-one cases of atopic dermatitis have been diagnosed (54 adults and 397 infants). Relative frequency of new cases of atopic dermatitis compared to new diagnosis was 0.37 p. 100 in 1992 and 0.72 p. 100 in 1998. Mean age was 3.2 years. A personal history of atopy was observed for 15.2 p. 100 of patients and a family history of atopy for 35.9 p. 100. A few numbers of complications were observed. Bacterial infections interested 15.3 p. 100 of cases. Hospitalisation was needed for 4 patients (0.88 p. 100). Class III and IV topical corticosteroids were usually used (84.8 p. 100). Potent corticosteroids (class I) were required for only 3.2 p. 100 of cases.We notice a low frequency of atopic dermatitis in this study and a predominance of mild forms of the disease. Other studies are needed to confirm these results and to determine the prevalence of atopic dermatitis in Tunisia.

We report forty-seven cases of bullous pemphigoid recorded in the dermatology department of Charles Nicolle hospital in Tunis during 16 years. In Tunisia, bullous pemphigoid is at the second rank of acquired autoimmune bullous skin diseases, after pemphigus. The profile of bullous pemphigoid in our series differ from that reported in the literature by the more young age (67.2 years) and the male predilection but don't present any clinical an epidemiological particularity. Three atypicals forms were observed: a vesicular form, a localized form and a infantile form. Systemic corticosteroids were choice treatment for our patients.

Human papillomavirus (HPV) infection tend to be the most prevalent sexually transmitted disease (STD), and "high-risk" HPV types are correlated to intra-epithelial neoplasia, especially cervical cancer. The aim of this study was to evaluate the frequency of "high risk" HPV types in condyloma.A non randomised prospective study was performed, including 24 patients with condyloma examined in the department of Dermatology of Charles Nicolle's hospital. Molecular hybridisation method was realised for all patients to identify HPV type.Mean age of the 24 patients was 37.8 years Ratio (male/female): 1.4 In 21 patients HPV DNA was detected 2 women had "high risk" HPV type (9.5%).

The incidence of condylomata acuminata is increasing in all countries. They are one of the most frequent sexually transmitted disease (STD). The authors reported the experience of the department of Dermatology of charles Nicolle's hospital between the year 1979 and 1998. This HPV infections were in the third position of the STD and occurred mainly in young males. The clinical lesions are genital condylomata. They were successfully treated with electrodessication or cryotherapy.

The aim of this retrospective study was to investigate therapeutic result of cutaneous lymphoma in Tunisia.Between January 1969 and June 1994, 100 patients with cutaneous lymphoma were referred either to Salah Azaiz Institute or the other University Hospitals of Tunisia. Fifty-one patients had epidermotropic lymphoma and 49 non-epidermotropic lesions. Eighty-seven patients received complete treatment. Puvatherapy and other local dermatologic treatments were used for early stage mycosis fungoïdes. Thirty-two patients benefited from radiotherapy, with curative dose in 28 cases. Chemotherapy including anthracyclin agents was used for high grade lymphoma. Thirteen patients had association of radiotherapy and chemotherapy.Five-year survival rates were 50% for patients with epidermotropic lesions and 56% for patients with non-epidermotropic cutaneous lymphoma. Statistical study has not identified any significant prognosis factor.Radiotherapy and chemotherapy are both effective. Treatment should depend on stage and histologic type.

Several studies have reported the association of cutaneous malignant melanomas (MM) with carcinomas. Collision malignancies cases from our files were retrieved. Among a series of 78,000 primary cutaneous cancers, 11 were collision tumors of MM with basal cell carcinoma and 106 were basosquamous carcinomas while no association was found between MM and squamous cell carcinomas. It is concluded that coexisting and confluent malignancies of the skin might not always be a random event.